Jenny Arthur was living at a pretty hectic pace. Working two jobs while pursuing a graduate degree had her stressed and rushing most of the time. Surprisingly, though, it was a relaxing weekend away that sent her into a tailspin. Arthur, then 30, had gone to Madison, Wis., to visit a friend, and the two spent the weekend visiting the farmers’ market, taking in films, wandering around the city, talking and drinking coffee — lots of it.
On the drive toward home, where all of her projects were waiting, Arthur started to feel strange. “My range of vision started getting narrower and narrower. My heart was racing, and I felt like I couldn’t breathe,” she recalls. “I had no idea what was happening to me.” She pulled off the freeway and called a friend who drove out and brought her to the nearest urgent-care clinic. “The doctor told me, ‘You’ll be fine. You’ve just had a panic attack.’”
Arthur, now 42 and an event planner in Minneapolis, is one of 40 million Americans who have been derailed by what psychiatrists call “anxiety disorders.” It’s a broad medical diagnosis that includes several distinct categories:
Obsessive-compulsive disorder, which consists of intrusive thoughts (obsessions) combined with repetitive behaviors (compulsions), such as excessive hand washing, that the sufferer performs to avoid the obsessive thoughts.
Panic disorder refers to recurring episodes of intense physical fear, without an obvious or immediate source of fear. These episodes, also called anxiety attacks, are commonly characterized by heart palpitations and may be accompanied by chest pains. It might also be difficult to breathe, and you may feel like you are choking (symptoms that can make the situation even more frightening and further ratchet up anxiety).
Posttraumatic stress disorder (PTSD) follows a severe traumatic event that threatens actual harm.
Social anxiety disorder describes the condition of people who suffer overwhelming anxiety when faced with everyday social interactions.
Generalized anxiety disorder is a catchall category that describes any chronic anxiety or exaggerated worry that lacks an obvious cause.
While these diagnoses, symptoms and distinctions sound clear-cut on paper, in practice they are anything but. In part, this is because separating the typical from the pathological isn’t always easy. The human brain, it seems, is hardwired to worry even under the best of conditions.
“Because we humans have prefrontal lobes, we can anticipate the future and make up a scenario that is harmful to us,” says Melissa Blacker, MA, a psychotherapist and associate director of the Stress Reduction Clinic at the University of Massachusetts Medical School’s Center for Mindfulness.
Some degree of anxiety and fear are normal responses to life. “Healthy anxiety is part of our fight-or-flight response system,” says Jonathan Abramowitz, PhD, director of the Anxiety and Stress Disorder Clinic at the University of North Carolina, Chapel Hill. “As a basic emotion, it is helpful. In fact, we would all be dead without it, because it protects us from harm.”
So where does a healthy emotional response to stress leave off and an anxiety disorder begin? “Anxiety is a response to the perception of threat,” Abramowitz explains. “When we’re talking about a real danger, that’s healthy stress and anxiety, but when the perception of threat is based on either a misinterpretation of the severity of the threat or the likelihood of harm, then we’re talking about a disorder.”
It can be hard, though, to objectively differentiate between a real threat and misinterpretation. A hostile coworker, for example, or a rash of burglaries in the neighborhood, may or may not constitute a genuine threat.
To further complicate the picture, the science guiding the treatment of anxiety disorders has been anything but clear-cut, opening the door for pharmaceutical companies to encourage consumers to self-diagnose and to seek out advertised products that may or may not be particularly effective in treating the disorders in question.
What’s clear is that the most promising approaches to managing anxiety — from its more acute manifestations to a chronic, low-level presence — involve clarifying both how it is triggered and how the body’s natural stress-coping mechanisms can be harnessed to bring it under control.
The Myth of the Magic Cure
In the fall of 2007, thousands of people requested more information about a condition known as “Dysphoric Social Attention Consumption Deficit Anxiety Disorder” and Havidol, a drug that promised to combat the disorder.
It turned out that both the disease and the drug (pronounced “Have-It-All”) were the invention of Australian artist Justine Cooper, who launched the elaborate parody campaign to draw attention to drug companies who were aggressively marketing their products directly to consumers. Not only did the satire fool members of the public, but the fake condition was briefly incorporated into medical Web sites as a new condition and treatment.
The Havidol hoax illustrates the complex and controversial reality of modern treatments for mental illnesses — especially those like depression and anxiety, which feature symptoms that overlap with normal human emotions.
Mental disorders are categorized and described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a book written by a committee of doctors to codify psychiatric conditions. Psychiatrists use the DSM to diagnose patients and prescribe medication; insurance companies typically require a DSM diagnosis before they approve payment for services.
The DSM, however, is a flawed document, says Christopher Lane, author of Shyness: How Normal Behavior Became a Sickness (Yale University Press, 2007). In researching the book, Lane conducted an exhaustive study of correspondence and interviews with doctors involved in compiling the 1980 DSM-III. “What I found was, frankly, very disturbing,” he says. “Some of the definitions lack a rigorous scientific rationale. Instead, you see capricious decision-making among close friends and colleagues who shared the same approach, while other approaches were left out. Some of the criteria are astonishing in terms of their carelessness and the absence of empirical justification from field studies.”
This carelessness, says Lane, opened the door to drug manufacturers to exploit the DSM categories in marketing their products. The United States and New Zealand are the only two countries in which direct-to-consumer advertising of drugs is legal, and pharmaceutical corporations spend millions to press their competitive advantage.
“GlaxoSmithKline spent almost $100 million promoting social anxiety disorder in what they called a public awareness campaign just two or three months after they got FDA approval for Paxil — then, the only pharmaceutical treatment available,” Lane explains. “Meanwhile, the psychiatric community went straight for medication and largely overlooked other forms of viable treatment.”
While medication can provide immediate relief from anxiety (although at the risk of side effects), long-term pharmaceutical treatment rests on the controversial 1950s-era theory that mental illness is caused by a “chemical imbalance” that can be corrected with medications. When the brain functions normally, it sends what can be thought of as a chemical code from one cell to the next using substances called neurotransmitters. When a person is depressed or anxious, levels of some of these neurotransmitters drop; thus, the notion that correcting the chemical balance corrects the condition.
Although the metaphor of an imbalanced brain persists, we now know that it’s a biological oversimplification. Neurotransmitters like serotonin and dopamine may be present in higher or lower levels during various emotional states — but that doesn’t necessarily mean they are the primary cause of those states. In fact, they can just as easily be seen as the result or biochemical product of emotional experiences.
Moreover, depression and anxiety are normal, predictable responses to certain life events, so any change in brain chemistry during these states can’t accurately or always be described as an “imbalance.” Neurotransmitters often play more than just one role in the brain and can act broadly to influence all sorts of body functions (serotonin, for example, has been shown to play a role in both mood and appetite), so interfering with their transmission can affect more than just mood — sometimes in unpredictable ways.
Drug interactions with brain chemistry are similarly broad: Any drug, whether cocaine or Prozac, affects our mental state by broadly repressing or enhancing our ability to manufacture, release or transfer certain neurotransmitters. Which is to say that increasing or suppressing the transmission of a selected neurotransmitter increases or suppresses all the roles that neurotransmitter plays in the brain, not just its one role in, say, anxiety. (For a look at how nutrition affects neurotransmitters and moods, see “Comfort Food for Your Brain.”)
But perhaps the most damaging aspect of the chemical imbalance theory is that it treats the brain in isolation from the rest of the body. In fact, they’re one highly integrated system.
Research has shown that our mental and emotional states are a complicated mix of brain chemistry and biology, as well as genetic, environmental and physical factors. Instead of thinking of the brain as some kind of isolated chemical lab that sends directions to the body, scientists now understand that our bodily experiences and our environments directly affect the functioning of the brain. Increasingly, doctors are recognizing this connection as an essential element in effectively treating disorders like anxiety.
The biological processes triggered by anxiety — sweaty hands, shallow breathing, increased heart rate, dizziness — are hardwired human responses to stressful situations. Most of these responses serve some biological purpose, such as preparing our bodies to react (fight or flee), or they are the byproduct of the chemicals, such as cortisol and adrenaline, that such a reaction might require. It’s when we perceive a major threat in situations where, objectively speaking, there is little or none — for example, in a crowded elevator (claustrophobia), crossing a bridge (fear of heights), leaving the house (agoraphobia) or at an office mixer (social anxiety) — that anxiety is classified as a disorder.
The more frequently or dramatically an unwarranted response occurs, and the more it interferes with a person’s daily life, the more severe that classification is likely to be.
Although pharmaceutical drugs can help moderate our bodies’ physical response to stressful thoughts or stimuli, nonpharmaceutical treatments — like cognitive behavioral therapy (CBT) — are beginning to replace drugs as the preferred treatment for anxiety disorders.
Unlike medications that attempt to suppress our physiological responses to perceived threats, CBT is aimed at correcting our perception of those threats, and thus encouraging a self-moderating response.
The first goal of CBT is simply education, says Abramowitz. “We teach people about their symptoms,” he explains. “We explain that when you feel nauseated, it’s not because you’re going to throw up; when your heart races, it’s not because you’re having a heart attack.” For many, just recognizing the symptoms of anxiety for what they are — and realizing that they do not represent an immediate danger — can prevent an attack from worsening.
The second phase of CBT focuses on exposure and response protection. Some CBT therapists actually place the sufferer in the situation that causes him or her fear — whether that situation is external, like playing with a large dog, or internal, like experiencing an accelerated heart rate. “When a person repeatedly confronts their fears, they learn that the outcomes they worry about aren’t nearly as likely as they think,” Abramowitz explains.
Moreover, they learn that the initial fight-or-flight response is transitory; anxiety eases when you’re able to stay in a situation and your fears aren’t realized.
It can take 10 to 15 sessions of CBT to produce lasting results, says Abramowitz, and the success rate is fairly high — as many as 70 percent of patients conquer their anxieties. (To find a cognitive-behavioral therapist near you, visit the National Association of Cognitive-Behavioral Therapists at http://nacbt.org/searchfortherapists.asp.)
Anxiety as a Physical Condition
The physical aspects of anxiety — our fight-or-flight response — are governed by the sympathetic nervous system. CBT works by essentially reprogramming our involuntary activation of this system. But other treatment approaches focus on the body’s parasympathetic nervous system, which regulates the healing, recharging part of the nervous system and helps shut off the fight-or-flight response.
Patricia Gerbarg, PhD, MD, a clinical psychiatrist at the New York Medical College and coauthor of How to Use Herbs, Nutrients, and Yoga in Mental Health Care (Norton, 2009), is studying how to activate the parasympathetic nervous system to quiet anxiety. She and her colleagues have discovered that some ancient practices are highly effective.
In particular, yoga breathing induces a very calm, clear-minded state — the opposite of the anxious fight-or-flight state of the sympathetic nervous system. “When you change the pattern of breathing,” explains Gerbarg, “it changes what happens in your emotion centers and thinking centers,” slowing the fight-or-flight actions of the amygdala and quieting the areas of the cortex that process worry.
Gerbarg and her colleagues have been able to quantify the effects of breathing techniques on the parasympathetic nervous system, and they are using what they’ve learned to train patients to interrupt anxiety with breathing. “We have seen some very rapid effects,” she says. “In five minutes, people may go from severe anxiety to complete relaxation.”
Gerbarg still prescribes medications when necessary to help relieve acute, debilitating symptoms and give alternative interventions a chance — but her long-term goal is to build the strength of the parasympathetic system, rather than to suppress the sympathetic.
Psychotherapist Kathryn Templeton, who spent 20 years working with soldiers suffering from PTSD at the National Center for Posttraumatic Stress Disorder at the U.S. Department of Veterans Affairs and now works with abused children, uses breathing and yoga extensively in her treatments. She has her patients begin by inhaling slowly for three counts and exhaling for six counts, a practice that cultivates awareness of their breathing patterns. “Breathing creates resiliency and releases tension,” she explains. It is physically impossible to breathe deeply and feel anxious at the same time.
The power of breath to reduce symptoms of anxiety helps illustrate how anxiety lives in both brain and body. Because anxiety is as much a physical condition as a mental one, a variety of physical activities can offer relief. Exercise in particular, writes Edward Hallowell in Worry: Hope and Help for a Common Condition (Random House, 1998), “is a terrific antidote for worry.”
Exercise quiets the anxiety response, not by changing the situation that is causing anxiety, he explains, but by changing “the vessel of your worry, the physical state of your body and brain.” He notes that exercise produces a variety of chemicals, such as endorphins, corticosteroids and neurotrophins, as well as various neurotransmitters like serotonin that can help soothe the worried mind.
If you start to feel anxiety welling up and you have even just a few free minutes, a couple treks up and down the stairs or a brisk walk around the block can work wonders, says Hallowell. You won’t always have the opportunity to break into a sprint when you feel your anxiety spiking, but, he continues, “A regular exercise program — exercise three or four times a week — will almost always cut down on worry. Exercise should be incorporated into any plan to reduce anxiety and control worry.”
Finally, no approach to anxiety management can be optimally successful unless it is supported by proper nutrition. Our brains require certain fats, proteins and nutrients to function normally and regulate mood — and no amount of yogic breathing or CBT can compensate for a mineral or omega-3-fat deficiency. (To learn more about what to eat to reduce anxiety and stabilize mood, see “Comfort Food for Your Brain.”) It is also important to limit your intake of stimulants such as caffeine, which prime the body and brain for heightened anxiety.
Mix Your Own Cure
After her first panic attack on the freeway in Wisconsin, Jenny Arthur went on to experience several more. After that, she says, “I started recognizing this vicious-cycle pattern. I would start to feel anxious and then I would think, ‘Oh God, am I going to have a panic attack?’” In turn, her increased anxiety about having one would fuel the onset of an actual panic attack.
This cycle was finally interrupted when her general practitioner recommended CBT treatments. CBT taught Arthur to calm her mind and put her physical reaction to stress in context. “I still use what the therapist taught me,” she says.
On the advice of her CBT therapist, Arthur also cut back significantly on caffeine. “The way he put it is, if I’m at a normal anxiety level of 30, then I’m stressed by work or school to level 60, then that café au lait puts me up to level 90 — that’s a lot closer to a panic attack at 100,” she says.
Arthur also uses yoga and controlled breathing to keep herself calm. “I find that yoga keeps my anxiety at a baseline so I don’t have to really think about it much. If I start to feel anxiety building, I do some yoga breathing and it goes away. I’m much more likely now to intervene quickly to keep it at a manageable level.”
Ultimately, regardless of whether or not you choose to treat your anxiety with medication, it makes sense to avail yourself of the full spectrum of other interventions, too — from good nutrition and regular exercise, to yoga, deep breathing and psychological approaches like CBT.
“Not every person will use every [approach],” writes Hallowell. “But every [approach] should at least be considered in order to achieve the best results.” That’s because, he notes, in almost all cases, no single approach alone will provide optimal results. Every individual has to find his or her own right mix.
In any life, anxiety is bound to come and go. But when it comes on strong enough to impede our health and happiness, it’s comforting to know that the remedies of modern science, ancient wisdom and simple self-care can all offer relief — and smart ways to keep future anxieties at bay.